PEDIATRIC OPIOID USE AND MISUSE Loma Linda University Pediatrics Project Advocacy Marti Baum, MD Alyssa Dann, MD
OBJECTIVES/OVERVIEW ➤ Pediatric Opioid Poisoning ➤ Non ‐ Medical Use of Opioids in Children and Adolescents ➤ Post ‐ operative and Prescription Opioid Use ➤ In ‐ utero Opioid Exposure and Neonatal Abstinence Syndrome ➤ Sports and Opioids ➤ Opioid Addiction and Treatment Options ➤ Safe Prescribing Practices and Opioid Monitoring Strategies
PEDIATRIC POISONING ➤ This study evaluated risk factors for unintentional opioid overdose or poisoning in young children and nonmedical/intentional use or overdose in adolescents. ➤ Efforts already implemented to decrease incidence of poisoning include child ‐ safe packaging. ➤ Safe storage defined as locked or latched for younger kids, and locked for older kids. Safe storage was reported in: ➤ 32.5% of households with only young children ➤ 11.7% of households with only older children ➤ 29.0% of households with children in both age groups McDonald, E. M., et. al . (2017). Safe Storage of Opioid Pain Relievers Among Adults Living in Households With Children. Pediatrics, 139 (3). doi:10.1542/peds.2016 ‐ 2161 Image source: https://www.checkupnewsroom.com/accidental ‐ overdose ‐ of ‐ a ‐ child ‐‐‐ mistaking ‐ pills ‐ for ‐ candy/
PEDIATRIC POISONING ➤ Perceived barriers to storing opioids in a locked place: ➤ More trouble than it’s worth, takes too much time ➤ Too hard for me to use my medication ➤ Most parents believe that storing opioids in a locked place is a good way to keep their child safe, whether or not they do it themselves. ➤ Most parents reported lower perception of threats and benefits with older children than with younger children. McDonald, E. M., et. al . (2017). Safe Storage of Opioid Pain Relievers Among Adults Living in Households With Children. Pediatrics, 139 (3). doi:10.1542/peds.2016 ‐ 2161 Image source: http://www.onlineparentingcoach.com/2012/03/teens ‐ who ‐ steal ‐ prescription ‐ drugs ‐ from.html
PEDIATRIC POISONING ➤ In a study in 2011, the most common cause of poisoning ‐ related deaths in children younger than 5 years was analgesics (21.1%). ➤ A single adult dose of an opioid can be enough to kill a child. ➤ Risk factors associated with pediatric poisonings: ➤ First in birth order ➤ Mother with perinatal depression ➤ A single adult in the household ➤ Maternal alcohol misuse ➤ Safety recommendations: ➤ Never store cleaners/medications in bottles or containers that were previously used for food. ➤ Don’t call medicine “candy” to get a child to take it. Canares, T. L. (2015). Poisoning Prevention. Pediatrics in Review, 36 (2), 82 ‐ 85. doi:10.1542/pir.36 ‐ 2 ‐ 82
PEDIATRIC POISONING ➤ Children of mothers prescribed opioids are at substantially greater risk of opioid toxicity. ➤ In this study of children age 10 and under, 50% of cases of opioid toxicity were in children <2yrs. ➤ The concurrent maternal use of antidepressants further increased risk of pediatric opioid overdose. ➤ Limitations: this study only includes prescription opioids, not the presence of illicit opioids in the household. Finkelstein, Y., Macdonald, E. M., Gonzalez, A., Sivilotti, M. L., Mamdani, M. M., & Juurlink, D. N. (2017). Overdose Risk in Young Children of Women Prescribed Opioids. Pediatrics, 139 (3). doi:10.1542/peds.2016-2887
PEDIATRIC POISONING AND NON ‐ MEDICAL USE OF OPIOIDS ➤ Review of a Poison Control database. ➤ Due to concern in the early 1990s that physicians were not adequately treating pain, opioid prescriptions quadrupled from 1999 ‐ 2010. ➤ 80% of opioid prescriptions worldwide are made in the US. ➤ Annual number of opioid exposures increased by 86.0% from 2000 ‐ 2009, then decreased by 31.4% from 2011 ‐ 2015. ➤ Buprenorphine exposures declined in 2011 ‐ 2013 then increased in 2014 ‐ 2015. ➤ Rate of suspected suicide by teenagers increased by 52.7% from 2000 ‐ 2015. Allen, J. D., et. al. (2017). Prescription Opioid Exposures Among Children and Adolescents in the United States: 2000–2015. Pediatrics, 139 (4). doi:10.1542/peds.2016 ‐ 3382 Image source: https://www.cnn.com/2017/09/18/health/opioid ‐ crisis ‐ fast ‐ facts/index.html
PEDIATRIC POISONING AND NON ‐ MEDICAL USE OF OPIOIDS ➤ Children ages 0 ‐ 5 had the largest number of exposures. ➤ Teenagers had greater odds of serious medical outcomes. ➤ Serious clinical side effects (total patients included: n=188,468): ➤ Respiratory depression (1.8%; n=3,386) ➤ Coma (0.8%; n=1479) ➤ Hypotension (0.4%; n=757) ➤ Respiratory arrest (0.2%; n=463) ➤ Cardiac arrest/asystole (n=0.1%; n=195) Allen, J. D., et. al. (2017). Prescription Opioid Exposures Among Children and Adolescents in the United States: 2000–2015. Pediatrics, 139 (4). doi:10.1542/peds.2016 ‐ 3382
NON ‐ MEDICAL USE OF OPIOIDS ➤ Review of data from the Monitoring the Future surveys given to 12th graders between 1975 and 2015. ➤ Findings: ➤ Medical use of opioids was the most prevalent opioid exposure. ➤ The majority of adolescents who reported nonmedical opioid use had previously used opioids medically. ➤ Male nonmedical opioid users are more like to use opioids prescription opioids to get high, while female are more likely to use them for physical pain relief. ➤ The decline in medical and nonmedical use of opioids from 2013 ‐ 2015 coincides with declines in opioid prescriptions during that time. Mccabe, S. E., West, B. T., Veliz, P., Mccabe, V. V., Stoddard, S. A., & Boyd, C. J. (2017). Trends in Medical and Nonmedical Use of Prescription Opioids Among US Adolescents: 1976–2015. Pediatrics, 139 (4). doi:10.1542/peds.2016 ‐ 2387
NON ‐ MEDICAL USE OF OPIOIDS ➤ Recommendations: ➤ Routine use of prescription drug monitoring programs to help identify misuse. ➤ Discussion with adolescents and parents about risks of benefits of pain management with and without prescription opioids including proper storage, monitoring, and disposal of medications. ➤ Routine screening for nonmedical opioid use and other substance use disorders ➤ Providing lowest effective dosages and minimum quantity with concomitant use of acetaminophen or ibuprofen to decrease opioid requirement. Mccabe, S. E., West, B. T., Veliz, P., Mccabe, V. V., Stoddard, S. A., & Boyd, C. J. (2017). Trends in Medical and Nonmedical Use of Prescription Opioids Among US Adolescents: 197
NON ‐ MEDICAL USE OF OPIOIDS ➤ About 467,000 adolescents ages 12 ‐ 17 years engage in non ‐ medical use of prescription pain relievers, and 168,000 are addicted (2014 National Survey on Drug Use and Health). ➤ 28,000 had heroin in the past year, 18,000 have a heroin use disorder. ➤ Starting at a younger age can be linked to increased severity of addiction. ➤ Most youths who start using opioids illicitly take prescription drugs that were prescribed for an adult. Kemp, C. (2016). AAP Conference Preview: Protect your patients from opioid addiction. AAP News . Image source: https://www.livescience.com/44036-heroin.html
NON ‐ MEDICAL USE OF OPIOIDS ➤ Baseline risk stratification of adolescents into three groups based on drug use behaviors, attitudes, grades, education level of parents, and ethnicity using data from the Monitoring the Future study. ➤ Those who were prescribed opioids as adolescents had a 33% higher risk of misusing them by age 23 compared to those who were never prescribed opioids. ➤ The most common reasons respondents gave for misuse were "to feel good or get high" and "to relax or relieve tension”. Miech, R., Johnston, L., Omalley, P. M., Keyes, K. M., & Heard, K. (2015). Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics, 136 (5). doi:10.1542/peds.2015-1364 Jenco, M. (2015). Study: Prescription opioid use in teens associated with future misuse. AAP News .
NON ‐ MEDICAL USE OF OPIOIDS ➤ Those who had negative attitudes about drugs and little experience using them (low risk groups on baseline stratification) were significantly more likely to misuse opioids in the future. ➤ Researchers theorized that adolescents who initially perceived as low ‐ risk may have gone on to misuse opioids due to the novelty. After having used them legitimately, they may have perceived them as safe and pleasurable. ➤ While this group was more likely to misuse opioids in the future, they did have low frequency of use (<5 uses in the past year). Miech, R., Johnston, L., Omalley, P. M., Keyes, K. M., & Heard, K. (2015). Prescription Opioids in Adolescence and Future Opioid Misuse. Pediatrics, 136 (5). doi:10.1542/peds.2015-1364 Jenco, M. (2015). Study: Prescription opioid use in teens associated with future misuse. AAP News .
POST ‐ OP/PRESCRIPTION ➤ Surgical care is one of the most common medical encounters associated with opioid prescription and is an important risk factor for prolonged prescription opioid use in adolescents. ➤ Retrospective cohort study of opioid naive adolescents and young adults comparing prolonged opioid use in post ‐ operative patients with prolonged use in a non ‐ surgical cohort. ➤ Prolonged opioid use was defined as a refill 90 ‐ 180 days after surgery. Harbaugh CM, Lee JS, Hu HM, et al. Persistent Opioid Use Among Pediatric Patients After Surgery. Pediatrics. 2018;141(1):e20172439 Image source: https://www psychiatryadvisor com/childadolescent psychiatry/adolescents psychiatric disorders rates of opioid use/article/752063/
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